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Review Article
Cerebrospinal fluid drains reduce risk of spinal cord injury for
thoracic/thoracoabdominal aneurysm surgery: A review
Nancy E. Epstein1,2
Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, 2Chief of Neurosurgical Spine and Education, Winthrop
1

NeuroScience, NYU Winthrop Hospital, Mineola, New York, USA

E‑mail: *Nancy E. Epstein ‑ nancy.epsteinmd@gmail.com

*Corresponding author

Received: 19 November 17   Accepted: 20 November 17   Published: 23 February 18

Abstract
Background: The risk of spinal cord injury (SCI) due to decreased cord perfusion
following thoracic/thoracoabdominal aneurysm surgery (T/TL‑AAA) and thoracic
endovascular aneurysm repair (TEVAR) ranges up to 20%. For decades, therefore,
many vascular surgeons have utilized cerebrospinal fluid drainage  (CSFD) to
decrease intraspinal pressure and increase blood flow to the spinal cord, thus
reducing the risk of SCI/ischemia.
Methods: Multiple studies previously recommend utilizing CSFD following
T/TL‑AAA/TEVAR surgery to treat SCI by increasing spinal cord blood flow.
Now, however, CSFD (keeping lumbar pressures at 5–12 mmHg) is largely
utilized prophylactically/preoperatively to avert SCI along with other modalities;
avoiding hypotension  (mean arterial pressures  >80–90 mmHG), inducing
hypothermia, utilizing left heart bypass, and employing intraoperative neural
monitoring [somatosensory (SEP) or motor evoked (MEP) potentials]. In addition,
preoperative magnetic resonance angiography (MRA) and computed tomographic
angiography (CTA) scans identify the artery of Adamkiewicz to determine its
location, and when/whether reimplantation/reattachment of this critical artery and
or other major segmental/lumbar arterial feeders are warranted.
Access this article online
Results: Utilizing CSFD for 15–72 postoperative hours in T/TL‑AAA/TEVAR Website:
surgery has reduced the risks of SCI from a maximum of 20% to a minimum of www.surgicalneurologyint.com
2.3%. The major complications of CSFD include; spinal and cranial epidural/ DOI:
10.4103/sni.sni_433_17
subdural hematomas, VI nerve palsies, retained catheters, meningitis/infection,
Quick Response Code:
and spinal headaches.
Conclusions: By increasing blood flow to the spinal cord during/after T/TL‑AAA/TEVAR
surgery, CSFD reduces the incidence of permanent SCI from, up to 10-20% down to
down to 2.3-10%. Nevertheless, major complications, including spinal/cranial subdural
hematomas, still occur.

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How to cite this article: Epstein NE. Cerebrospinal fluid drains reduce risk of spinal cord injury for thoracic/thoracoabdominal aneurysm surgery: A review. Surg Neurol Int
2018;9:48.
http://surgicalneurologyint.com/Cerebrospinal-fluid-drains-reduce-risk-of-spinal-cord-injury-for-thoracic/thoracoabdominal-aneurysm-surgery:-A-review/

© 2017 Surgical Neurology International | Published by Wolters Kluwer - Medknow

Surgical Neurology International 2018, 9:48 http://www.surgicalneurologyint.com/content/9/1/48

Key Words: Abdominal aneurysm (T/TL‑AAA) surgery, cerebrospinal fluid drainge

(CSFD), complications, lumbar, spinal hematomas, subdural hematomas, TEVAR
lumbar drain, thoracic

INTRODUCTION potentials (MEP)], and using magnetic resonance

Here we reviewed the pros, cons, and complications
of cerebrospinal fluid drains (CSFD) used in
thoracic/thoracoabdominal aneurysm surgery (T/
TL‑AAA)/thoracic endovascular aneurysm
repair (TEVAR) [Tables 1‑3]. Previously, without
preoperative placement of CSFD, the incidence
of spinal cord injury (SCI)/paraplegia following T/
TL‑AAA/TEVAR approached 20%; unfortunately the
failure to prophylactically place CSFD resulted in too
many permanent paraplegic injuries. Now since most
surgeons prophylactically place CSFD to increase spinal
cord perfusion, the risk of SCI has been reduced to 2.3-
10% [Tables 1‑3]. Additional adjunctive measures to
decrease SCI with CSFD include; avoiding hypotension,
using hypothermia, selectively employing left heart
bypass, routinely performing intraoperative neural
monitoring [somatosensory (SEP) or motor evoked
angiography (MRA) and computed tomographic
angiography (CTA) to identify and reimplant critical
lumbar/intercostal arteries including the artery of
Adamkiewicz. However, major risks/complications of
CSFD include; spinal/cranial subdural hematomas, VI
nerve palsies, retained catheters, meningitis/infection,
and spinal headaches.
MATERIALS AND METHODS
We identified 18 articles utilizing PubMed and the
terms “Thoracic/Thoracoabdominal Aortic Aneurysm
Surgery (T/TL‑AAA),” “Thoracic Endovascular Aneurysm
Repair (TEVAR),” “Cerebrospinal Fluid Drainage (CSFD),”
and “Spinal/Neurological Complications” to assess the pros,
cons, risks, and complications without and with CSFD in
patients undergoing these procedures [Tables 1‑3].

Table 1: Risks/complications of cerebrospinal fluid drains in T/TL‑AAA/TEVAR surgery (1999‑2002)

Author Surgery# patients Lumbar drain Clinical history Complications Treatment outcome
reference
year
Rosenthal TL‑AAA 18 Patients SCI Average surgery 16 Aortic Cross Clamps Paraplegia Postop
1999.[16] Not routine use Preop CTA/MRA 3 h 39 min Infrarenal 6‑20 h
CSFD location of ICA‑AKA Average aortic clamp 48 min 2 Suprarenal 5 received CSFD‑no improvement
Jacobs TL‑AAA Surgery Complications Protocol to decrease SCI: Protocols to decrease SCI: 2.3% SCI risk
2000.[10] 170 MEP SCI Hypothermia, Left heart bypass
Monitoring Renal Failure CSFD MEP monitoring
Mesenteric Infarction Reattach arteries
McHardy T‑L AAA Lumbar Drain/CSFD Died 5 days after Type III Subdural Hemorrhage Fatal SDH
2001.[15] Case Study TL‑AAA
63 year Male
Jacobs TL‑AAA Protocol; Intercostal‑Lumbar arteries 183/184 MEP nl. Neural deficit 2.7%
2002.[11] 184 Patients Left heart Bypass Grafted or 1 Plegic/MEP loss
Monitor MEPs CSFD Oversewn 4 Normal MEP/deficits;
IONM‑MEPs 2 Transient
2 Permanent
Dardik TL‑AAA 8 SDH (3.5%) Pressures for drain SDH Average CSF 6 SDH
2002.[8] 230 Patients Average age 60.6 >5 mm H (2) 0; drainage: 9.3 Days Postop
Preop CSFD SDH: Due to Drains Removed 3 Days 690 cc One‑1.5 mos.
Over Drainage No SDH; One‑ 5 mos.
Average drainage 4 of 8 Died
359 cc
Ackerman 6 Cases 6th Patient: Acute Treatment; 6 Treated CSFD: Duration CSFD 15‑72 h.
2002. [1]
TL‑AAA Thrombus Raised BP over 70 mm HG 4 Improved Pressure <10 mm Hg
5 Delayed 2 Not improved
12‑40 h.
Due to Hypotension
TEVAR: Thoracic Endovascular Aneurysm Repair; T/TL‑AAA: Thoracic/Thoracolumbar Abdominal Aortic Aneurysm; SCI: Spinal Cord Injury; CSFD: Cerebrospinal Fluid
Drainage; LD: Lumbar Drains; ICA‑AKA: Intercostal‑Lumbar Artery‑Adamkiewicz Artery; MRA: Magnetic Resonance Angiography; CTA: Computed Tomographic Angiography;
IONM: Intraoperative Neural Monitoring; AE: Adverse Events; MEPs: Motor Evoked Potentials; ID: Identification; SEP: Somatosensory Evoked Potential Monitoring; BP: Blood
Pressure; ECC: Extracorporeal Circulation; SDH: Subdural Hematoma; hrs: Hours; yo:Year old; nl: Normal; preop: Preoperative
Surgical Neurology International 2018, 9:48 http://www.surgicalneurologyint.com/content/9/1/48

1986 definition of Crawford types I–IV of TL‑AAA
In 1986, Crawford described four types of TL‑AAA.[11]
Type I included the majority of the descending thoracic
aorta from the left subclavian to the suprarenal
abdominal aorta. Type II extended from the subclavian
to the aortoiliac bifurcation (most extensive). Type III
included the distal thoracic aorta to the aortoiliac
bifurcation. Type IV involved the abdominal aorta below
the diaphragm.
Canine study; CSFD avoids SCI with experimental
thoracic aortic occlusion
To determine the onset of SCI, Benicio et al.
cross‑clamped the descending thoracic aorta (60 minutes)
in 18 canines divided into 3 groups; 6 controls (only
aortic cross clamping), 6 with ischemic preconditioning,
and 6 with prophylactic CSFD (e.g. lumbar drains
opened just before cross clamping) [Table 2].[3] At 7
postoperative days, the Tarlov neurological scores were
significantly higher for the animals receiving CSFD, and
they demonstrated faster/fuller recovery of adverse SEP
changes.
Incidence of spinal cord injury/paraplegia with
and without CSFD
The risk of spinal cord injury (SCI) without CSFD for
TL‑AAA ranges up to 20%, while with CSFD it was
reduced to 2.3–10% [Tables 1‑3].[1,2,4‑6,10‑13,16,17]
Higher incidence of SCI without preoperative CSFD for
T/TL‑AAA/TEVAR
Several studies documented the higher rates (10-20%)
of SCI occurring when CSFD was not employed prior
to TL‑AAA/TEVAR surgery [Tables 1 and 2].[1,2,13,16]
In 1999, Rosenthal et al. identified 18 patients who
exhibited SCI after TL‑AAA [Table 1].[16] Notably,
preoperative CTA and MRA did not help avoid
ICA‑AKA (Intercostal‑Lumbar Artery–Adamkiewicz
Artery injuries). When paraplegia was diagnosed in
5 patients (6 to 20 hours postoperatively), all underwent

Table 2: Risks/complications of cerebrospinal fluid drains in T/TL‑AAA/TEVAR surgery (2003‑2009)

Author Surgery# patients Lumbar drain Clinical history Complications Treatment outcome
reference year
Cheung 2003.[4] 162 CSFD Placed Intact Patients LD clamp CSFD Paraplegic 4.9%
TL‑AAA L3‑L5 24 hrs. 135 TL‑AAA (8 of 162)
Extracor‑poreal Pressure 10‑12 Removed 48 hrs. 27 T‑AAA No hematomas
circulation (ECC) mmHg Plegic Patient: Left heart 6 (3.7%) Adverse Events:
CSFD CSFD placed SCI drain kept >24 h. bypass partial/ 1‑VI palsy
Anti‑ 153 min. Before total arrest/+/‑ 3‑Retained catheter
Coagulation Heparin hypothermia 2 Meningitis
Avg. age 67 1 Spinal headache
Mortality 14.1%
Cheung 2005.[5] 75 Stents Minimize Risk of SCI Maintain Mean BP SCI Due to: SCI 6.6%
T‑AAA with Early exam >90 mm HG 1 Bleed (5 patients)
TEVAR Postop CSF Pressure <10 mm (retroperitoneal) 2 LE SEP Loss After Stent
Average Age 75 SEP 23 CSFD 2 Prior AAA Placement
Increase BP 15 SEP 1 Iliac injury 5 Paraplegic:
CSFD 1 Embolism 2 recovered >BP
3 recovered with >BP and CSFD
Coselli 2007.[6] TL‑AAA 546 (23.9%) Chronic 139 (6.1%) Ruptured Left heart bypass 615 (26.9%)
2286 Dissection Aneurysms 30 days survival CSFD
Open Surgery 78 (3.4%) Acute 2191 (95%) 87 (3.8%) SCI
1662 (72.7%) Deg. Dissection
aneurysms no dissection
Benicio 2007.[3] Experimental 18 Canines Descending 6 Cross Clamped 6 CSFD Group: CSFD: Faster Recovery SEP
Thoracic Aortic Preconditioned 6 CSFD Better 7 Day Tarlov Monitoring
Occlusion before cross clamping Scores
Bajwa 2008.[2] Case Paraplegia Reversed with CSFD Case: Reversal Case: Reversal paraplegia with
TEVAR paraplegia with CSFD
TL‑AAA CSFD
Martin 2009.[13] TEVAR CTA 27 SCI (10%) >Risk SCI: >Risk SCI:
TL‑AAA 2000‑200 13 Reversed with CSFD Older, Male History of AAA Repaired/
261 Patients 14 Stayed Plegic Emergency unrepaired
General Anesthesia (39%‑101/261)
TEVAR: Thoracic Endovascular Aneurysm Repair; T/TL‑AAA: Thoracic/Thoracolumbar Abdominal Aortic Aneurysm; SCI: Spinal Cord Injury; CSFD: Cerebrospinal Fluid Drainage;
LD: Lumbar Drains; ICA‑AKA: Intercostal‑Lumbar Artery‑Adamkiewicz; MRA: Magnetic Resonance Angiography; CTA: Computed Tomographic Angiography; IONM: Intraoperative
Neural Monitoring; AE: Adverse Events; MEPs: Motor Evoked Potentials; ID: Identification; SEP: Somatosensory Evoked Potentials; BP: Blood Pressure; ECC: Extracorporeal
Circulation; SDH: Subdural Hematoma; hrs: Hours; Avg: Average; min: Minutes; Deg: Degenerative; LE: Lower Extremity
Surgical Neurology International 2018, 9:48 http://www.surgicalneurologyint.com/content/9/1/48

Table 3: Risks/complications of cerebrospinal fluid drains in T/TL‑AAA/TEVAR surgery (2010‑2016)

Author Surgery# Lumbar drain Clinical history Complications Treatment outcome
reference year patients
Sinha 2010.[18] TL‑AAA Higher Risk: Reduce Risks: Reduce Risks: Early Detection of SCI
Risks SCI Open Surgery CSFD Reattach Segmental with
Prior AAA Increase BP Arteries IONM
Hypotension Early exam
Fedorow TL‑AAA CSFD Risks: CSFD Risks: Hematoma, CSFD Risks: Excessive Risks infection
2010.[9] Nerve Damage Intracranial Bleed Drainage/Clots
Matsuda TEVAR Intercostal Lumbar Ages 57‑89 Protection; SCI 4‑All
2010.[14] 60 Artery to Adam ICA‑AKA using MRA or CTA IONM/MEPs Received CSFD:
Distal TL‑AAA kiewicz Artery Patient ICA‑AKA after Identification Avoid Low BP 3 Better
T7‑L2 ICA‑AKA) Early Diagnosis SCI Use CSFD 1 Stayed Plegic
Coselli 2016.[7] Risks TL‑AAA Risks SCI Protection: Protection CSFD with Multiple
TL‑AAA: Passive Hypothermia Hypothermia Measures provide
Death CSFD CSFD Increased Protection
Paraplegia Left Heart Bypass Bypass vs. SCI
Renal failure Reimplant Crucial Intercostal/ Reimplantation
SCI Lumbar Arteries Critical Vessels
Scott 2016.[17] TL‑AAA Extensive Fenestrated Avoid SCI: Avoid SCI: Risks SCI 10% with
Endovas‑cular Aortic CSFD Staged Procedures‑ CSFD
Grafts Avoid Hypotension Increase Collaterals Also Elevate BP
IONM
Hypothermia
Khan 2016.[12] Meta‑analysis Lumbar Drains‑CSFD for SCI with TL‑AAA Avoid Over‑drainage SCI 20% without CSFD
10 Articles TL ‑ AAA Without CSFD‑ 20% with CSFD SCI 10% with CSFD
With CSFD ‑10% Increases Risks of
Hematoma
TEVAR: Thoracic Endovascular Aneurysm Repair; T/TL‑AAA: Thoracic/Thoracolumbar Abdominal Aortic Aneurysm; SCI: Spinal Cord Injury; CSFD: Cerebrospinal Fluid
Drainage; LD: Lumbar Drains; ICA‑AKA: Intercostal‑Lumbar Artery‑Adamkiewicz Artery; MRA: Magnetic Resonance Angiography; CTA: Computed Tomographic Angiography;
IONM: Intraoperative Neural Monitoring; AE: Adverse Events; MEPs: Motor Evoked Potentials; ID: Identification; SEP: Somatosensory Evoked Potential Monitoring; BP: Blood
Pressure; ECC: Extracorporeal Circulation; T‑AAA: Descending Thoracic AAA; AAA: Abdominal Aortic Aneurysm; SDH: Subdural Hematoma

immediate placement of lumbar drainage/CSFD:
unfortunately, none recovered. In 2002, Ackerman
and Traynelis found 5 patients who developed the
delayed (12 and 40 hours) onset of SCI after TL‑AAA
surgery again without CSFD [Table 1].[1] Placement of
CSFD 15–72 hours postoperatively (e.g. after patients
became paraplegic), maintaining lumbar CSF pressures
under 10 mm Hg, and elevating their systemic blood
pressures (mean of >70 mmHg) reversed deficits in
just 4 of 6 patients. In 2008, Bajwa et al. reversed
paraplegia following TEVAR for TL‑AAA (infrarenal)
utilizing CSFD [Table 2].[2] For Martian et al. (2009),
10% (27 patients) of 261 patients undergoing TEVAR
without CSFD developed SCI; 13 (48%) recovered with
CSFD, while 14 (52%) did not [Table 2].[13]
Reduction of SCI with preoperative placement of CSFD for
T/TL‑AAA/TEVAR
The placement of CSFD prior to T/TL‑AAA/TEVAR
surgery reduced the postoperative incidence of SCI
to 2.3–10% [Tables 1‑3].[4‑6,12] In 2003, Cheung et al.
utilized CSFD (e.g. lumbar drains placed at L3‑L5
levels; CSF pressures maintained between 10 and
12 mmHg) along with extracorporeal circulation
([ECC]/left heart bypass) for 135 patients undergoing 98
TL‑AAA and 27 T‑AAA [Table 1].[4] The time between
lumbar drain insertion and full anticoagulation (e.g. to
avoid creating spinal/subdural hematomas) was
153 minutes. Postoperatively, for intact patients, drains
were clamped at 24 hours, and removed at 48 hours; for
plegic patients (e.g. with SCI) drainage was maintained
for over 24 hours. SCI occurred in 4.9% (8 of 162) of
the patients in this series, while another 6 (3.7%) had
catheter‑related complications including 1 transient
VI nerve palsy (over drainage), 2 retained catheters, 1
retained catheter/meningitis, 1 meningitis alone, and
1 spinal headache. In a second study (2005), Cheung
et al. evaluated 75 patients (averaging 75 years of
age) undergoing distal T‑AAA [Tables 1 and 2].[5] SCI
occurred in 5 patients (6.6%); 2 recovered by just
increasing the BP, whereas 3 required both raising the
BP and placing CSFD. When Coselli et al. evaluated
2286 conventional open TL‑AAA repairs (2007), 615 had
prophylactic CSFD; SCI occurred in 3.8% patients (87
of 2286) [Table 2].[7] After Matsuda et al. (2010)
utilized CSFD in all 60 patients undergoing TEVAR,
3 of 4 (6.6%) who developed SCI recovered with
additional adjunctive measures, while one remained
plegic [Table 2].[14] In a meta‑analysis of 10 studies
involving T/TL‑AAA/TAVER, Khan et al. (2016)
Surgical Neurology International 2018, 9:48 http://www.surgicalneurologyint.com/content/9/1/48
observed the 20% incidence of SCI occurring without
CSFD, and noted the reduction of this number to 10%
with CSFD [Table 3].[12]
Risk factors for SCI with TL‑AAA/TEVAR surgery
Several studies cited risks factors for SCI occurring after
TL‑AAA//TEVAR [Tables 1‑3].[5,6,13,14,17,18] These included;
older age, male sex, more emergencies, general anesthesia,
a history of prior aortic surgery, a history of prior diagnosis
of AAA, open surgery, intraoperative hypotension, and more
extensive/lengthy aneurysm surgery (e.g. Crawford Type II).
Measures to prevent SCI
Multiple measures utilized to prevent SCI following
TL‑AAA/TEVAR included; prophylactic placement
of CSFD, increasing the mean arterial blood pressure
(>80–90 mmHg), mild passive hypothermia, early
neurological assessment postoperatively to detect the
onset of paraparesis/paraplegia, evaluation of preoperative
MRA/CTA to determine the necessity of reimplanting
intercostal/lumbar arteries, staging surgical procedures to
promote collateral circulation, identifying the vascular supply
to the artery of Adamkiewicz, and the use of intraoperative
neural monitoring (IONM: SEP/MEP) [Tables 1‑3].[7,14,17,18]
Intraoperative neural monitoring limits
paraplegia following TL‑AAA surgery
Following TL‑AAA/TEVAR surgery, the acute/subacute
onset of SCI was typically attributed to reduced spinal cord
perfusion (e.g., decreased collateral circulation/perfusion
of the artery of Adamkiewicz, hypotension), resulting in
increased spinal cord ischemia/edema/reperfusion injury,
and increased intraspinal pressures [Table 1].[1,10,11] In 2000,
Jacobs et al. noted in 170 patients undergoing TL‑AAA
surgery that the incidence of SCI was reduced to just 2.3%
using a combination of CSFD plus; motor evoked potential
monitoring (MEP), hypothermia, distal aortic perfusion, and
revascularization of segmental arteries [Table 1].[10] Following
184 TL‑AAA in 2002, Jacobs et al. (2002) again limited the
incidence of postoperative SCI to 2.7% utilizing CSFD,
IONM/MEPs, revascularization (e.g. of intercostal/lumbar
arteries for MEP amplitude loss of >25%), plus left heart
bypass [Table 1].[11] Of the 5 patients with new postoperative
neurological deficits, just one lost all MEP (MEP remained
normal in 183); 2 of the remaining 4 without significant
MEP changes exhibited transient, whereas the other 2
exhibited permanent paraplegia.
Multiple adverse events still result from CSFD
utilized in T/TL‑AAA/TEVAR surgery
Many adverse events were still attributed to utilizing
CSFD to avoid SCI for patients undergoing T/
TL‑AAA/TEVAR [Tables 1 and 3].[8,9,15] These included;
direct neural injury, epidural/intraaxial spinal hematomas,
intracranial bleeds/subdural hematomas (e.g., due to
excessive drainage), and infection [Table 3].[9]
Subdural Hematomas (SDH) resulting from CSFD
Nine acute SDH were reported in two studies.[8,15] McHardy
et al. (2001) reported a 63‑year‑old male who received a
prophylactic CSFD for a Crawford Type III TL‑AAA: he
expired 5 days later from an acute SDH [Table 1].[15] For
230 patients in Dardik’s study (2002) where CSFD were
routinely placed preoperatively, 8 (3.5%) developed acute
SDH; 50% died [Table 1].[8] In the latter study, patients
averaged 60.6 years of age, and those who developed SDH
drained nearly twice the amount of CSF (e.g. 690 cc with
SDH vs. 359 cc) as those without SDH.
CONCLUSIONS
Without CSFD, patients undergoing T/TL–AAA/TEVAR
sustained up to a 20% risk of SCI, while with CSFD, SCI
were reduced to a minimum of 2.3% [Tables 1‑3]. Most
vascular surgeons now prophylactically place CSFD prior
to T/TL‑AAA/TEVAR surgery. Nevertheless, complications
of CSFD still include; spinal/cranial subdural hematomas,
VI nerve palsies, retained catheters, meningitis/infection,
and spinal headaches.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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